FINANCIAL ASSISTANCE POLICY

Transcription

1 FINANCIAL ASSISTANCE POLICY I. PURPOSE/OBJECTIVE The mission at DeKalb Medical is to deliver high quality healthcare services that improve the health and well-being of the patients served by DeKalb Medical. DeKalb Medical understands that not all patients have the ability to completely pay their healthcare bills. To eliminate financial barriers for patients who are uninsured, under insured, or have limited means to pay for emergency and non-elective medically necessary services provided in the hospitals of DeKalb Medical and its outpatient facilities, DeKalb Medical has adopted this (FAP). DeKalb Medical will provide these hospital medical services in a consistent manner to all emergent patients, without regard to race, creed, gender, color, national origin, handicap, immigration status, ability to pay, or other characteristics covered by law and will not take any actions that discourage individuals from seeking emergency medical care, such as by demanding that emergency department patients pay before receiving treatment for emergency medical conditions or by permitting debt collection activities that interfere with the provision, without discrimination, of emergency medical care. II. COVERED ENTITIES The facilities of DeKalb Medical include the North Decatur, Hillandale, Decatur Long-Term Acute Care Hospital and other hospital outpatient locations. A list of all physicians providing services, including emergency and/or other medically necessary care, at these locations is available at However, this FAP does not apply to any physicians who provide services at DeKalb Medical. Patients may receive a separate bill from the primary treating physician as well as for professional services provided by radiologists, pathologists, anesthesiologists, emergency room and other treating physicians. III. COVERED PERSONS Page 1 of 8

2 This policy applies to patients who are Georgia residents and who are uninsured (i.e., those patients without third-party payer coverage for health care services) or under-insured (i.e., those patients with insufficient third-party payer coverage for health care services). Patients who are deemed eligible under DeKalb Medical s guidelines for the FAP may apply for financial relief toward the patient s portion of eligible amounts owed for services rendered. This policy applies only to emergency and other medically necessary care. Guidelines for determining FAP approvals are approved by the Chief Financial Officer of DeKalb Medical. The FAP is not a substitute for personal responsibility. Patients are expected to cooperate with DeKalb Medical in determining eligibility for various programs. IV. AMOUNTS GENERALLY BILLED DeKalb Medical applies the look-back method for determining Amounts Generally Billed (AGB). In particular, DeKalb Medical determines AGB for emergency and/or other medically necessary care by multiplying gross charges for that care (i.e., DeKalb Medical s full established rates) by the AGB Percentage for such care. DeKalb Medical calculates AGB Percentages at least annually by dividing the sum of all claims for emergency and other medically necessary care that have been allowed by Medicare fee-for-service and all private health insurers during a prior 12-month period by the sum of the associated gross charges for those claims. When including allowed claims in calculating its AGB Percentages, DeKalb Medical includes the full amount that has been allowed by the health insurer, including both the amount the insurer will pay or reimburse and the amount (if any) the individual is personally responsible for paying in the form of copayments, co-insurance, and deductibles, regardless of whether or when the full amount allowed is actually paid and disregarding any discounts applied to the individual's portion. The AGB Percentages utilized by DeKalb Medical at any particular time is available here or in writing and free of charge by mail by calling (404) V. FINANCIAL ASSISTANCE ELIGIBILITY CRITERIA Financial assistance is available under this FAP for emergency and other medically necessary care provided to uninsured and underinsured patients of DeKalb Medical who are Georgia residents and satisfy the following eligibility criteria. Financial assistance is approved on a percentage basis as a reduction from gross charges (i.e., the full established rates for the provision of healthcare services) according to the guidelines below: 100% assistance for patients with family household resources less than 300% of Federal Poverty Level (FPL) guidelines 75% assistance for patients with family household resources between 300% to 350% of FPL guidelines 60% assistance for uninsured patients with family household resources above 350% of FPL guidelines Page 2 of 8

3 A net worth of $100,000 may render a patient ineligible for financial assistance under this FAP. DeKalb Medical will not charge patients eligible for assistance under this FAP more than AGB for emergency and/or other medically necessary care (the AGB Limitation ). To be eligible for complete financial assistance under the FAP, a patient s household income must not exceed 300% of the FPL guidelines. For any patients not eligible for complete financial assistance, the patient is responsible for the remainder of the outstanding amount after the patient s account is reduced as described above. In order to be eligible for financial assistance, patients must make good faith effort, as determined by DeKalb Medical, to obtain coverage from available public assistance programs (i.e. Medicare, Medicaid, Crime Victim s Assistance, Auto Carrier, etc.). Financial assistance is not applicable to an insurance company s or benefit plan s payment responsibility under a health benefits plan, regardless of whether the insurance company or health plan has made payment to the patient or to DeKalb Medical. Financial assistance under this FAP does not apply to deductibles and co insurance amounts after patients accounts have been adjudicated by their insurance companies; provided, however, that such amounts shall be included in applying the AGB Limitation. DeKalb Medical may adjust the eligibility criteria for the FAP periodically based upon the Community Health Needs Assessment (CHNA) conducted for DeKalb Medical and as necessary to comply with the Internal Revenue Service, Medicare program or other applicable laws and regulations. Any such changes will be reflected in this policy. Additional discounts may be available for certain patients outside this FAP. The following criteria may be taken into consideration when determining whether such additional discounts shall apply: The patient/guarantor s household income as compared to the FPL guidelines Whether the total patient account balance is significant relative to the patient/guarantor s household annual income Other financial resources that are potentially available to pay for health care services provided, including, but not limited to, Medicare, Medicaid, commercial insurance or other third party coverage Availability of health insurance Extenuating circumstances of the patient/guarantor affecting ability to pay account or to support dependents Whether the patient/guarantor has become unemployed Georgia residency VI. APPLICATION PROCESS Page 3 of 8

4 To be considered for financial assistance under this FAP, uninsured and under insured patients (who are not presumptively eligible) must complete a FAP application. A key element of the FAP is the disclosure of any and all sources of insurance and/or means of payment to establish proof of need. A completed FAP application must include all required identity and residency supporting documents and income verification information to assist the Financial Counseling employees of DeKalb Medical determine the eligibility for full or partial financial assistance. Patients who are not determined to be presumptively eligible for 100% financial assistance may apply for financial assistance by contacting or visiting the DeKalb Medical Financial Counseling Departments and completing the financial assistance application. The DeKalb Medical Financial Counseling Departments, which can provide information about this FAP and assistance with the FAP application process, are located by the main information desks at the North Decatur and the Hillandale hospital locations. Financial Counseling Department telephone number: Mailing Address: 2710 North Decatur Road, Decatur, Georgia VII. REQUIRED DOCUMENTS TO DETERMINE ELIGIBILITY The following items, including identity verification, residency, income and dependent information, are needed to determine eligibility for the FAP. Identification - The original or a certified copy of at least one of the following documents is required: Passport Driver s license State of Georgia ID card School picture ID Visa or Residence Alien Card (if applicable) Residency One to three of the following documents showing the patient s current street address is required to verify place of residency: One to three utility bills: power, gas, cable, water, telephone Lease contract Rent receipt (showing current address) Food stamps letter Voter registration documentation P.O. Box addresses do not demonstrate residency Credit card statements Latest IRS tax return Medicaid letters Student letters from school Page 4 of 8

5 Bank statement Mortgage statement Check stubs showing your address P.O. Box addresses do not demonstrate residency Income One of the following is required: One to three current pay check stubs (patient and spouse) Unemployment claim Department of Labor (DOL) wage inquiry Recent bank statements, if patient is living off saving A letter from an employer on company letterhead stating the rate of hourly pay, the total amount paid each pay period and how often the employee is paid Any decision letter indicating the patient is receiving unemployment compensation, Medicaid, Social Security disability, general assistance, etc. Food stamps letter and pay check stubs (if applicable) Verification of homelessness or a letter from a shelter on company letterhead Other business documents showing how the patient is being supported Number of dependents One of the following is required: Previous year s income tax return (most recent) Any decision letters indicating that the patient has legal responsibility for the child, such as, court ordered guardianship papers or custody papers Birth certificate for each child age 18 and younger VIII. ADMINISTRATIVE PROCEDURES 1. The first step of the process to determine identity and proof of residency. 2. The next step is income verification. The patient will be required to produce one or more of the following: pay stubs, W-2 forms, tax returns, employer written statement, wage inquiry statement, Department of Labor wage inquiry, unemployment claim, credit report, food stamps letter, bank statements if patient is living off savings, verification of homelessness or letter from a shelter on company letterhead, or an approved indigent care trust fund attestation form. 3. Dependent information requires one of the following: previous year s tax return, any decision letters indicating that the patient has legal responsibility for the child or children, such as a court ordered guardianship papers or custody paper, birth certificate for each child age 18 and younger. 4. Any patient requesting financial assistance must complete a FAP application and provide all required verifications. Refunds of amounts paid to DeKalb Medical by the patient before the application is approved will be made if applicable. 5. As a part of the FAP process, DeKalb Medical utilizes a third-party company to conduct an electronic review of patient information in order to assess each patient s financial need. This review utilizes a healthcare industry-recognized model that is Page 5 of 8

6 based on public record databases. This predictive model incorporates public record data to calculate a socio-economic and financial capacity indicator that includes estimates for income, assets and liquidity. The electronic technology is designed to assess each patient to the same standards and is calibrated against historical approvals for DeKalb Medical s financial assistance under the traditional application process outlined below. The information returned by this modeling application will be considered adequate documentation for financial assistance under the FAP. This process is considered presumptive eligibility. 6. If a patient is presumptively determined to be eligible for less than 100% financial assistance, DeKalb Medical will notify the patient regarding the basis for the presumptive eligibility determination and the manner in which the patient may apply for more assistance under this FAP. 7. This process also includes an electronic search of patient s information to determine whether a patient currently has active insurance. 8. All patient accounts which are not automatically eligible through the above presumptive eligibility process can be still approved for financial assistance using the guidelines set forth in this FAP (including FPL guidelines) as a tool for determining eligibility. To be eligible for 100% assistance, the patient s household income must not exceed 300% of the FPL. A record of all financial assistance writeoffs will be maintained by the Financial Counselor Department and will be stored in an Electronic Medical Record under the Charity tab. 9. An approval of the FAP application will be considered as an approval for future accounts for up to (3) months of the approval date. After such time, each new account will require new verification information to be considered for financial assistance. Medicaid, or other third party coverage, that may be retroactive would nullify any financial assistance previously granted on the duplicate balance. 10. FAP applications will be taken by a Financial Counselor, the Financial Assessment Manager, or appointed designee in the absence of the above. 11. FAP applications may be submitted prior to admission (prior approval by Financial Assessment Manager only), during admission, and any time after discharge. 12. An account balance remaining after a patient has exhausted all efforts to obtain coverage from other programs will be eligible for financial assistance; however, the patient must make a good faith effort, as determined by DeKalb Medical, to obtain coverage from available public assistance programs (i.e. Medicare, Medicaid, Crime Victim s Assistance, Auto Carrier, etc.). A patient who refuses to apply or follow through with applications for other assistance will not be eligible for financial assistance. 13. In the event that the patient is faced with a financially catastrophic medical bill, the Financial Assessment Manager or the Director of Patient Access will make a discretionary recommendation that the patient is medically indigent and thus eligible for financial assistance. This determination will be made on a case-by-case basis and will require a more intense verification process. Page 6 of 8

7 14. DeKalb Medical reserves the right to reverse financial assistance approvals if the information provided by the patient is later determined to be falsified or if compensation for services is obtained from another source. 15. If it is determined during admission that a patient is eligible for Medicaid but later denied, DeKalb Medical reserves the right to use the documents presented during the Medicaid application process to automatically approve the patient for financial assistance. 16. If a Medicaid application is pending for more than 180 days, DeKalb Medical reserves the right to automatically approve the patient for financial assistance using the documents presented during the application process. If the patient is later approved, the financial assistance decision will be reversed. 17. There is no minimum balance to apply for financial assistance. 18. DeKalb Medical makes this FAP, the financial assistance application form, and a plain language summary of this FAP widely available on its website at In addition, DeKalb Medical makes paper copies of this FAP, the financial assistance application, and a plain language summary of this FAP available, upon request and without charge, in its Admissions and Registration areas and emergency rooms. Patients may also request free paper copies by mail by contacting the DeKalb Medical Financial Counseling Department at the mailing address or phone number listed above. 19. DeKalb Medical translates this FAP, the financial assistance application form, the plain language summary of the FAP, and the AGB Percentages for limited English proficient individuals representing the lesser of five percent (5%) or 1,000 individuals of the community served by its hospital facilities. Free copies of such translated documents are available in the same manners as described above. IX. ACCOUNT BALANCES Accounts under $10,000 will be reviewed and adjusted by a Financial Counselor. Accounts that are between $10,000 and $100,000 will be reviewed and adjusted by the Financial Assessment Manager and/or Financial Counselor Supervisors. Accounts greater than $100,000 will be reviewed and adjusted by the Director of Patient Access and/or Financial Assessment Manager. X. ACTIONS IN THE EVENT OF NONPAYMENT DeKalb Medical does not conduct, or permit collection agencies to conduct on its behalf, Extraordinary Collection Actions (ECAs) as defined under Section 501(r) of the Internal Revenue Code, against individuals before reasonable efforts have been made to determine whether the patient is eligible under this FAP. ECAs include selling an individual s debt to another party; reporting adverse information about the individual to consumer credit reporting agencies or credit bureaus; deferring or denying, or requiring payment before Page 7 of 8

8 providing, medically necessary care because of nonpayment of previous bills; actions that require a legal or judicial process, including but not limited to placing a lien on individuals property (other than liens placed on proceeds of a judgment, settlement or compromise owed to an individual receiving health care services as a result of personal injury). DeKalb Medical may take such actions after reasonable efforts have been made to determine eligibility under this FAP. DeKalb Medical may take actions that do not constitute ECAs, including referring debt to a collections agency, provided such collections agency does not engage in any ECAs prior to DeKalb Medical making reasonable to determine whether the patient is eligible under this FAP. The Financial Counseling Department has the final authority and responsibility for determining whether DeKalb Medical has made reasonable efforts to determine whether an individual is eligible under this FAP and whether an ECA is appropriate. Patients with a balance due will have 120 days from the date of the first billing statement to respond. Under no circumstance will DeKalb Medical take an ECA prior to the expiration of such 120 day period. At least 30 days prior to taking an ECA, DeKalb Medical will: 1. provide the patient with a written notice that indicates financial assistance is available for eligible individuals, identifies the ECAs that DeKalb Medical intends to initiate to obtain payment for the care, and states a deadline after which such ECAs may be initiated that is no earlier than 30 days after the date that the written notice is provided; 2. provide the patient with a plain language summary of this FAP; and 3. make a reasonable effort to orally notify the patient about this FAP and about how the patient may obtain assistance with the application process. The financial assistance application period begins on the date medical care is provided and ends 240 days after the first post-discharge billing statement or 30 days after DeKalb Medical or an authorized third party provides written notice of ECAs the hospital plans to initiate, whichever is later. If a patient submits an incomplete financial assistance application during the application period, DeKalb Medical will suspend ECAs, notify the patient about how to complete the application, and give the patient a reasonable opportunity to do so before resuming any ECA activity. If a patient submits a complete financial assistance application during the application period, DeKalb Medical will suspend ECAs and make an eligibility determination before resuming any ECA activity. Page 8 of 8